INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 13-14, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Narcotic Addict Rehabilitation Program of Thomas Jefferson University was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on January 18, 2011.
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Plan of Correction
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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on an inspection of the facility's physical plant and an interview with the Program Coordinator, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
An inspection of the facility's physical plant was conducted on December 14, 2010 at approximately 2:00 PM. The two client bathrooms on the first floor of the facility did not have individual paper towels or a mechanical dryer at the time of inspection.
An interview with the Program Coordinator on December 14, 2010 confirmed that the identified bathrooms did not have paper towels or a mechanical dryer.
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Plan of Correction
At the direction of the Facility Director, individual paper towels have been returned to each bathroom. In the meantime, we continue to explore installation of mechanical dryers. It will be the responsibility of the Facility Director and Program Coordinator to periodically inspect the restrooms to ensure compliance. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on an inspection of the facility's physical plant and an interview with the facility director, the facility failed to prohibit the use of heaters that are not permanently mounted or installed.
The findings include:
An inspection of the facility's physical plant was conducted on December 14, 2010 at approximately 2:00 PM. One portable space heater was observed in the office of the Account Representative, and another portable space heater was observed in the group room on the second floor.
An interview with the facility director on December 14, 2010 confirmed the use of heaters that were not permanently mounted or installed.
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Plan of Correction
It is the responsibility of the facility director to ensure that licensure requirements are met. Staff have been reminded that non-permanently installed heaters are forbidden. Periodic review of the environment of care will ensure that such heaters are not used. |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on the review of client records and an interview with a senior therapist, the facility failed to document follow-up information in two of four client records.
The findings include:
Four client records were reviewed on December 14, 2010 for follow-up information. The facility did not document follow-up information within sixty days from the date of discharge, as per facility policy, in client records # 4 and 5.
The facility's policy titled "Follow-up Information" states:
"It is the policy that patients who are discharged from the program because of any reason other than being transferred or referred (e.g. treatment completion, AWOL) receive follow-up contact. Follow-up information is typically collected 60 days after discharge by means of a two page follow-up form. "
Client record #4 was discharged on 9/17/10, but follow-up information was not documented at the time of review on 12/14/10.
Client record #5 was discharged on 8/4/10, but follow-up information was not documented at the time of review on 12/14/10.
An interview with a senior therapist on December 14, 2010 confirmed that follow-up information was not documented for clients # 4 and 5.
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Plan of Correction
New policies and procedures with respect to follow-up have been agreed upon. Specifically, at the time of discharge, administrative support personnel will attempt to contact former patients for the purpose of administering a newly designed follow-up questionnaire. Success at contact efforts will be documented at this time. It will be the responsibility of the program coordinator to ensure that these actions are conducted as proposed. |